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HCAHPS Update Training February 2009

HCAHPS Update Training February 2009. Welcome!. In the HCAHPS Update Training sessions, we will: Explain purpose and use of HCAHPS survey Provide instruction on managing the survey Discuss modes of survey administration

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HCAHPS Update Training February 2009

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  1. HCAHPS Update TrainingFebruary 2009

  2. Welcome! In the HCAHPS Update Training sessions, we will: • Explain purpose and use of HCAHPS survey • Provide instruction on managing the survey • Discuss modes of survey administration • Instruct on sampling, data preparation, data submission and public reporting

  3. HCAHPS Program Updates

  4. Overview of Presentation • HCAHPS Upcoming events • New for HCAHPS • Participation in HCAHPS • How to Join HCAHPS in 2009

  5. Upcoming for HCAHPS March 26, 2009 Fifth public reporting of HCAHPS results; July 2007-June 2008 discharges; ~3,800 hospitals April 8Submission deadline for 4th quarter 2008 data April 10 - May 9Preview Period for June public reporting ~ June 18 Sixth public reporting of HCAHPS results ~ September 17 Seventh public reporting of HCAHPS results ~ December 17 Eighth public reporting of HCAHPS results

  6. New for HCAHPS • IPPS hospitals must report HCAHPS results on Hospital Compare website • Enhanced oversight • New languages added for mail mode • HCAHPS Mode Experiment Two • Testing feasibility of two new candidate modes: • SE-IVR and Web-based • New footnotes

  7. New for HCAHPS(cont’d) • HCAHPS Bulletins • HCAHPSExecutive Insight • HCAHPS Version 3.1 effective for second quarter 2009 discharges • Hospitals with 5 or fewer HCAHPS-eligible patients need not survey from January 2009 • However, still must submit header data • Congress considering HCAHPS in possible pay-for-performance program

  8. Public Reporting MARCH 2009 • QUARTERS INCLUDED: 3Q07, 4Q07, 1Q08, 2Q08 • PREVIEW PERIOD: January 19 – February 17 • PUBLIC REPORTING: March 26, 2009 • NOTE: First reporting of hospitals that joined HCAHPS in July 2007 • Data from 2Q07 has rolled off

  9. Survey Mode Second quarter 2008 hospitals (3,866): • Mail: 2,833 hospitals; 73% • Telephone: 990 hospitals; 26% • Mixed: 8 hospitals; 0.2% • IVR: 35 hospitals; 1%

  10. Participation in HCAHPS Second quarter 2008: • 50 Approved survey vendors • 93 Self-administering hospitals • 5 Multi-site hospitals

  11. Oversight and Compliance As HCAHPS plays a greater role in hospital payment, The importance of oversight and compliance increase

  12. Steps to Join HCAHPS in 2009 • Submit HCAHPS Participation Form • For self-administering hospitals, hospitals administering survey for multiple sites and survey vendors • Form now available online • Do an HCAHPS Dry Run • Voluntary, but strongly suggested • Last month of calendar quarter • Contact HCAHPS Project Team for details • HCAHPS@azqio.sdps.org • Collect and submit HCAHPS survey data on continuous basis

  13. More information on HCAHPS • Registration, applications, background information, reports, updates and HCAHPSExecutive Insight: www.hcahpsonline.org • Submitting HCAHPS data: www.qualitynet.org • Publicly reported HCAHPS results: www.hospitalcompare.hhs.gov

  14. Questions?

  15. HCAHPS Participation and Program Requirements

  16. Participation Overview • Quality Assurance Guidelines V4.0 • Quality Assurance Plans • Exceptions Request/Discrepancy Report • HCAHPS Website

  17. HCAHPS Quality Assurance Guidelines V4.0 • General updates: • Terminology changes • Web site; My QualityNet; CMS Certification Number • Updates to Introduction and Overview • Mode Experiment II information • Updated 2009 timeline • Program Requirements • Reminder that the HCAHPS survey must be administered before any other survey • Data submission for “zero case” and fewer than 5 eligible discharges in a month • Maintain counts of ineligible patients and exclusions

  18. HCAHPS Quality Assurance Guidelines V4.0(cont’d) • General updates (cont’d): • Additional methodologies approved to determine HCAHPS service line • Sample Frame must be maintained for 3 years • Two new mail survey translations • Updates to the Telephone and IVR scripts • XML File Layout 3.1 • Appendices

  19. Quality Assurance Plan (QAP) • QAP 2009 submission date March 23, 2009 • Appendix N • Revisions must be clearly identified (track changes) • Must include a discussion of the results of quality control activities conducted during the prior year

  20. Quality Assurance Plan (QAP) (cont’d) • QAP 2009 submission date March 23, 2009 (cont’d) • Include sample(s) of survey and cover letter (Mail Only and Mixed modes) • Include sample(s) of telephone script (screen shots Telephone Only and Mixed modes) • Include sample(s) of IVR Script (Active IVR mode) • All survey languages administered

  21. HCAHPS Exceptions Request • Exceptions Request required to use a service line determination methodology other than: • V.26 or V.25 MS-DRG codes • V.24 CMS-DRG codes • Mix of V.26, V.25, V.24 codes based on payer source • ICD-9 codes • Hospital unit • New York State DRGs

  22. HCAHPS Exceptions Request • Exceptions Request must be submitted online via the HCAHPS Web site • Survey Vendors must submit Exceptions Request on behalf of their contracted hospital • Organization submitting the Exceptions Request will receive notification emails

  23. Discrepancy Report • Discrepancy Reports must be submitted online via the HCAHPS Web site • Survey Vendors must submit Discrepancy Report on behalf of their contracted hospital • Organization submitting the Discrepancy Report will receive notification emails • Detailed information and hospital CCN required • Reviewed each reporting period

  24. Discrepancy Report (cont’d) • Reviewed each reporting period • Timing of notification emails

  25. HCAHPS Web site • Regular update items • HCAHPS Executive Insights • PMA Tables • Data Submission Due Date Announcements • HCAHPS Bulletin • Online Form Submission

  26. Questions?

  27. Sampling Protocol

  28. Overview • Steps of Sampling Process • Population, Sample Frame and Sample • Sampling Facts

  29. Steps of Sampling Process • Population (All Patient Discharges) • Identify Eligible Patients • Remove Exclusions • De-Duplication Process • HCAHPS Sample Frame • Draw Sample See Quality Assurance Guidelines V4.0, Flowchart of HCAHPS Sampling Protocol

  30. Step 1: Population(All Patient Discharges)

  31. Step 1: Population (cont’d) • Patients of all payer types are eligible for sampling • Hospitals contracting with survey vendors are strongly encouraged to provide entire patient discharge list (excluding no-publicity patients and patients excluded because of state regulations) to their survey vendor

  32. Step 2: Identify Eligible Patients Ineligible Patients Record count of Ineligible patients • All Eligible • Patients • 18 years or older at the time of admission • Admission includes at least one overnight stay in the hospital • Non-psychiatric MS-DRG/principal diagnosis at discharge • Alive at the time of discharge

  33. Step 2: Identify Eligible Patients Eligibility Criteria(cont’d) • V.26 MS-DRGs effective October 1, 2008 • To classify into Medical and Surgical service lines • The Federal Register Notice – most recent August 19, 2008 (updated approximately twice per year) • To classify into Maternity Care service line • Use MS-DRGs 765 – 768, 774, 775 • Current Service Line-MS-DRG Crosswalk Table • Quality Assurance Guidelines V4.0

  34. Step 2: Identify Eligible Patients Eligibility Criteria (cont’d) • Effective with Version 3.1 2Q 2009 patient discharges - accepted methodologies for determination of service line (Exceptions Request not required) • V.26 orV.25 MS-DRG codes • V.24 CMS-DRG codes • Mix of V.26, V.25, V.24 codes based on payer source • ICD-9 codes • Hospital unit • New York State DRGs Hospitals/Survey vendors must submit an Exceptions Request Form online for approval to use other means.

  35. Step 2: Identify Eligible Patients Eligibility Criteria (cont’d) • Include patients unless have positive evidence that a patient is ineligible • Missing or incomplete MS-DRG, address and/or telephone number does not exclude patient from being sampled • Nursing home patients must not be excluded

  36. Step 2: Identify Eligible Patients Eligibility Criteria (cont’d) • Do not include patients with discharge dates beyond the 42-day initial contact period in the sample frame • Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol

  37. Step 3: Remove Exclusions Ineligible Patients • Exclusions • “No-Publicity” patients • Court/Law enforcement patients (i.e., prisoners) • Patients with a foreign home address Patients discharged to hospice care • Patients who are excluded because of state regulations All Eligible Patients

  38. Step 3: Remove Exclusions(cont’d) • Record count of patients by each exclusions category • Hospitals/Survey vendors must retain documentation that verifies all exclusions

  39. Step 4: De-Duplication Process Ineligible Patients Exclusions All Eligible Patients • De-Duplication • Household • Multiple Discharges

  40. Step 4: De-Duplication ProcessDe-Duplication by Household • Sample only one patient per household in a given calendar month • De-duplicate address and/or telephone number from medical records and patient unique IDs within each month • Do not de-duplicate address and/or telephone number for nursing homes, long-term care facilities, etc., unless residents are family members

  41. Step 4: De-Duplication ProcessDe-Duplication by Multiple Discharges • Sample patient only once in a given calendar month • For continuous sampling, only use the first discharge date • For weekly sampling, use the last discharge during the week • For end of the month sampling, de-duplicate across all discharges in the month and only use the last discharge Patients are eligible to be included in the sample in consecutive months.

  42. Step 5: HCAHPS Sample Frame Ineligible Patients Exclusions All HCAHPS Eligible Patients (Sample Frame) • De-Duplication • Household • Multiple Discharges

  43. Step 5: HCAHPS Sample Frame Sample Frame Creation • Survey vendor generates sample frame (Recommended) • Contracted hospital submits their entire patient discharge list, excluding no-publicity patients and patients excluded because of state regulations • Survey vendor applies Eligible Population criteria and removes Exclusions and generates the sample frame before sampling

  44. Step 5: HCAHPS Sample FrameSample Frame Creation(cont’d) • Hospital generates sample frame • File contains all patients that meet Eligible Population criteria • Hospital provides all required data file elements • Total count of ineligible patients • Total count of patients by each exclusions category • Survey vendor validates the integrity of the sample frame before sampling

  45. Step 5: HCAHPS Sample Frame Sample Frame Creation(cont’d) • Include all patients: • Who meet eligible population criteria • Discharged between first and last days of month • Include patients even if: • Missing or incomplete address/telephone number • Missing eligibility criteria

  46. Step 5: HCAHPS Sample Frame Sample Frame Creation(cont’d) • Do not include patients if: • Discharge dates beyond the 42-day initial contact period if known before sample drawn • Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol • Include these patients towards the count in the Eligible Discharge field

  47. Step 5: HCAHPS Sample FrameHCAHPS Sample Frame • Must maintain sample frame for a minimum of three years • Updated sample frame layout (Appendix K) • File Content (i.e., All Patient Discharges or HCAHPS Sample Frame) • Total Number of Ineligibles • Total Number of Exclusions and by Exclusions Category • Total Number of Patient Discharges

  48. Step 6: Draw Sample Eligible Patients Not Selected for Sample Ineligible Patients Exclusions De-Duplication • Sample • Simple Random Sample (SRS) • Proportionate Stratified Random Sample (PSRS) • Disproportionate Stratified Random Sample (DSRS)

  49. Population, Sample Frame and Sample Population (All Patient Discharges) A + B + C + D + E= Hospital Population (All Patient Discharges) A + B = HCAHPS Sample Frame: generated by hospital/survey vendor. Contains entire Eligible Population A = Sample: randomly selected A B C D E Sample Drawn

  50. Sampling Facts • Same sampling type must be maintained throughout the quarter • Sample must include discharges from each month in the 12-month reporting period • HCAHPS random sample drawn first if multiple surveys administered • Do not stop sampling/surveying if 300 completes attained

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